What would Toronto neurologist Dr. Sharon Cohen do if a patient wished to escape the slow, inescapable torment of a terminal disease through suicide?

Would she agree to help if the patient asked?

She pauses thoughtfully for several seconds.

“I’ll say no,” she finally declares, her eyes rising to make direct contact.

Has she assisted patients to die in the past?

“Again, I’ll say no.”

It’s the kind of careful phraseology used by many Canadian physicians torn between the threat of imprisonment for assisting a death in Canada and the instinct to help patients pleading for relief.

“Are you going to find physicians who are willing to come forward and attest to the cases where they broke the law?” Cohen says. “No. But physician-assisted dying is happening all the time.”

Countries including Belgium, Switzerland, the Netherlands and Luxembourg have all adopted various forms of liberal laws around assisted death and euthanasia.

Even in the U.S. — which many Canadians see as more politically and culturally conservative — Oregon and Washington have legalized physician-assisted suicide for people with terminal illnesses.

In Washington, 103 people requested and received prescriptions for lethal drugs last year. Seventy used them. In Oregon, 114 people obtained prescriptions, and 71 used them.

Massachusetts is considering a similar law in a vote next month.

In Canada the practice remains illegal — even though many say it continues to take place.

One in five of the two dozens physician interviewed for this story say they’ve provided, or know colleagues who have provided, some form of support to terminally ill patients seeking to end their lives.

Physician surveys in the U.K. and the U.S. starting in the 1990s report a minority — generally ranging between 6 and 20 per cent — willing to assist patients end their lives.

“I hear about it from doctors who assure me it’s happening in medical contexts,” says Wayne Sumner, a University of Toronto philosopher and author of Assisted Death.

“It reminds me of the abortion situation 30 years ago. The law says one thing, but you’ve got doctors who simply refused to cooperate.”

And like abortion prior to legalization, convictions against physicians would be difficult even if authorities could prove incidents of illegal assisted death, says Sumner.

“In abortion, people responded to compassion on the part of physicians. These are people taking a personal risk to provide abortion and acting on compassionate grounds. Likewise in this case, juries would respond to compassion.”

Few physicians are willing to test that theory, however.

They’re fearful, says Cohen. For their reputations, their medical licenses, the antipathy of those who disagree.

“There’s fear that physicians will be cast in a negative light and that religious bodies and others will lose confidence in the medical profession,” says Cohen, the 57-year-old medical director of the Toronto Memory Program. “Those fears are a very poor reason not to speak out.”

In April, one of Cohen’s patients — Nagui Morcos — took his own life in a suicide he had carefully planned with his wife.

He decided to wrest control from Huntington’s disease, which was overtaking his body.

In the months leading up to his chosen day of death, Morcos shared his plans with Cohen. She listened. And despite legal and professional concerns, she offered her support.

Morcos completed the act without her direct involvement.

But even emotional support for a patient taking his life is a rare public admission for a doctor in Canada, where a code of silence around such conversations is firmly entrenched in the medical profession.

Consistent with Canadian law, most of the country’s medical governing bodies are opposed to assisted death. So taking a principled stand, even within the quiet confidence of colleagues, can trigger career-ending attacks from within.

There are some visceral examples, burned into the minds of Canadian physicians that illustrate what can happen to a doctor seen to be offering the promise of a speedy death to patients.

A judge eventually dismissed the charges, saying there was insufficient evidence to show the injection had caused the death of the 65-year-old patient. But the incident created big headlines, a reprimand from Morrison’s provincial governing body and a chilling legacy for members of her profession.

Morrison declined a request for an interview.

It’s a disposition shaped by her history.

She is the daughter of a Holocaust survivor mother from wartorn Europe who, along with her own mother, made ammunition for German soldiers in a concentration camp.

They were the fortunate ones in the family.

The rest of her family on her mother’s side was exterminated.

“I was very affected by the fact that people suffered,” she says. “How does one live a moral, ethical life in what one does? How does one do the most one can for people?”

From a young age, she was fascinated with the human brain and human behaviour.

As a child she’d spend hours in her room dissecting her beloved pets after they had died, prying the tiny brains of mice and hamsters from their cranial cavities and plopping them into Heinz baby food bottles filled with vinegar.

As a medical student in Toronto, she became troubled with how physicians under pressure would treat patients without proper consideration of the implications.

“I watched countless brain-dead patients being kept alive with catheters and tubes and invasive monitoring,” she recalls. “I couldn’t see a point to it. It was inhumane. And wasn’t it supposed to be the physician’s job to be humane and to know when to stop?

“I don’t know how any sensible person can’t believe in an assisted death if their life isn’t worthy of living.

“I do believe in Christianity and that what Jesus preached is absolutely valid,” continues McPhee, who was raised in the Church of Scotland. “But I don’t believe in what organized religions preach.”

McPhee’s systemic lupus has triggered several health problems that could eventually bring serious illness, she says. And her Sjogren’s disease dries her body’s membranes requiring eye drops several times a day and other treatments — care she says she’s unlikely to get in a hospital or care facility if she were immobilized.

She fears the point at which discomfort will turn to misery.

And she fears that if death does eventually become preferable to life, the means of accomplishing will prove impossible under current legal restrictions.

“Putting a plastic bag over your head is not 100-per-cent foolproof,” she says. “If I started getting breathless, I’m not sure I could do it.”

Violent acts aren’t an option for her either.

What she wants — and knows she can’t have — is a physician to help her.

“I think of it quite a lot. If I knew somebody could give me a pill, I’d have a much happier life. I can’t think of many things that would make me happier than to hear that physician-assisted dying is legal. But I don’t count on it.

“When animals are suffering, we put them down. Why don’t we do the same for humans?”

Medical tradition and the health-care mythology portrayed in TV doctor dramas celebrate the saving and maintaining of a heartbeat at all costs.

That may be the right choice for many patients.

But not for all, Cohen says.

Too often, the final choice is paternalistic, made by governments, legislators or physicians without much consideration of the ailing person’s wishes.

She returns to the question.

What is the moral choice? And what restrictions does the law place on that choice?

The answer is shrouded in grey.

“There’s no clarity,” Cohen says. “The law says you can’t assist an individual in the dying process or in hastening their death. But what does that mean? Does that mean you can’t have a conversation with them on this topic?

“Does it mean you must implement treatments you know are futile or continue all treatment previously initiated? Does it mean that you are liable if an individual discloses a plan to end their life and you don’t try to prevent them?”

She doesn’t know.

Now the senior medical adviser for the U.S. right-to-die group Final Exit Network, MacDonald claims involvement in nearly 200 “death hastenings” across North American over the past 15 years.

When he graduated from the University of Alberta in 1952, there was no prohibition against helping patients to die peacefully when they were close to the end, he says.

That changed in the 1970s, when helping end a life became controversial.

It never made sense to him.

And he says he’s far from alone.

“Most deaths these days are medicalized, totally controlled by the medical profession,” he says. “I would say, qualitatively, in the time you and I have been speaking there have been patients who have been assisted to die by their physicians. I think it goes on in every country when a patient and physician have a close relationship that has been established.”

The process can be easily conducted with plausible deniability. But a physician’s intentions are obvious, he says.

Many doctors increase pain medicine or give very strong sedatives that will speed up the process. That might not end a life in an hour or two, but it will provide a peaceful death over a period of hours or days.

“It’s what we used to call the ‘wink, wink,’ syndrome. A doctor says, ‘This sedative should give you a good night’s sleep if you take one but it could end your life if you take them all.’ ”

Like most North American right-to-die advocates, MacDonald wants to see progressive, European-style legislation allowing for controlled and safe assisted death.

“It’s a sensible, rational approach to people who are near dying,” he says.

The pace of legal evolution has been glacial in Canada, he argues.

“Politicians don’t really want to touch the subject, but they’re being forced to by the public.”

But they are also pushed in the opposite direction by fierce opposition to the notion of legalizing assisted death.

“Other jurisdictions clearly indicate that the number of assisted deaths increases after legalization and abuse continues.”

The 2010 study published in the British medical journal, for example, found only about half of assisted deaths in Belgium in 2007 were reported and reviewed by the country’s Federal Control and Evaluation Committee.

“Just because it is legal doesn't make it safe.”

Would she wish to end her own life is she faced the kind of intractable disease she sees in her patients?

“I don’t know the answer,” she says. “I’ve seen tremendous strength in people who decide to live on. And I’ve seen some people who are heartbreaking because the best thing for them is for their life to end. I would never say that to them, but sometimes I know it.”

In those moments, when a patient pleads for help, the confusing, messy, amorphous questions of law and morality re-emerge.

Her eyes make direct eye contact again, glistening this time.

“People don’t think about how physicians feel about this,” she says. “I would want to assist, but the law says I can’t.”

Robert Cribb is a 2012 Atkinson research fellow who has spent the past four months examining how Canadians face the end of life. These stories are part of a series that continues over the next two months.

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